Any opinions, findings, conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of UK Essays.

Introduction

Inflammatory bowel disease (IBD) is an immune mediated chronic gastrointestinal disorder that comprised of both Crohn’s disease and ulcerative colitis. The disease is characterized by remission (disease free interval) and relapse (active disease) (Van de star & Banan, 2015). Genetics, environment, immunology and microbiomes play a major role in the development of IBD (Ananthakrishnan, 2015). About 1.5 million Americans, 2.2 million Europeans and more than hundred thousand worldwide are affected by IBD (Ananthakrishnan, 2015). According to the recent data, the incidence of IBD is increasing in Asian countries, Africa and South America where IBD was considered as a rare disease previously (Ananthakrishnan, 2015).

Due to the chronic nature of the disease and an early onset, IBD impairs both physical and psychosocial well-being of the affected population. These patients may undergo a mixture of emotions which can ultimately end up with anxiety, and depression (Van de star & Banan, 2015).The highest prevalence of anxiety and depression among IBD patients is consistently reported in many previous published data (Nahon, et al., 2012; Panara, et al., 2014; Neuendorf, Harding, Stello, Hanes, & Wahbeh, 2016). A systematic review on the depression and anxiety in patients with inflammatory bowel disease presented 35% prevalence rate of anxiety symptoms followed by 22% of depressive symptoms among IBD patients (Neuendorf et al., 2016).

Multiple factors lead to anxiety and depression in IBD patients. Severe and active disease were reported as the main risk factors of anxiety and depression in IBD patients followed by female gender and socioeconomic deprivation or low socioeconomic status (Panera et al.,2014; Clark et al., 2014; Nahon et al.,2012). Nahon et al (2012) reported that adverse effects of the treatment itself or the fear of side effects can lead to anxiety and depression among IBD patients. Additionally, the treatment with corticosteroids can trigger mood disturbances (Nahon, et al., 2012). Moreover, the effects of psychological stress on the disease activity of patients with IBD were documented previously (Sajadinejad, Asgari, Molavi, Kalantari, & Adibi, 2012). Stress response mediates IBD as a result of involvement of brain- gut-axis that leads to the secretion of peripheral corticotrophin releasing factor which alters intestinal motility, and increased intestinal permeability that reduces mucosal barrier action and makes it more prone to inflammation (Sajadinejad et al., 2012). Furthermore, stress leads to the dysfunction of the intestinal immune system results in attacking the intestinal mucosa itself and the activation of hypothalamic -pituitary-adrenal axis that results in secretion of stress hormones such as cortisol and release of inflammatory mediators such as cytokines (Sajadinejad et al., 2012). Furthermore, the study by Caneo, Marston, Bellon, and King (2016) confirmed an increased risk for depression among patients with physical illness related to systemic inflammation compared to patients with physical illness without inflammation. The above report is applicable to IBD patients due to the chronic inflammatory nature of the disease.

The above evidences are suggestive of the burden of IBD patients’ due to anxiety and depression and highlights the need to manage anxiety and depression with effective psychological interventions. Considering the chronic inflammatory nature of IBD and the connection between brain -gut-axis that leads to stress response and inflammation (Sajadinejad et al., 2012), evaluation of available psychological interventions is necessary to recommend it as an adjuvant therapy with pharmacological management to manage anxiety and depression among IBD patients. McCombie, Mulder, & Gearry (2015) studied the coping strategies and psychological outcomes of IBD patients and recommended to focus on psychological interventions to improve the adaptive strategies of IBD patients.

Currently, only one review is available about the effects of psychological interventions on anxiety and depression, but the results are insufficient as the study ended up with a pharmacological intervention (Fiest et al., 2016). The researchers of other reviews that addressed psychological interventions, focused on many outcomes such as disease activity, psychological comorbidity and quality of life (QOL); many studies included in the review were old and none of them focused on anxiety or depression as a primary or secondary outcome. Hence, there is a need for synthesizing new evidence on the effectiveness of psychological interventions on anxiety and depression and this review solely focuses on the available psychological interventions for anxiety and depression in patients with IBD.

Problem Statement and Purpose

Many psychological interventions are documented in the literature to manage anxiety and depression among IBD patients. But, most of them are lacking controlled clinical trials to synthesize evidence to support its effectiveness to manage anxiety and depression. The primary purpose of this review is to identify the randomized controlled trials (RCT) of existing psychological interventions for depression and anxiety among IBD patients. The following research questions were formulated:

What psychological interventions are currently available in the literature to support the evidence for the management of anxiety and depression among IBD patients?

What outcome measures were identified through psychological interventions in managing anxiety and depression among IBD patients?

Methods

Search strategy

The search strategy was guided by the research questions to identify the potentially relevant studies in peer reviewed journals. The electronic databases of PubMed, CINAHL, EMBASE, PsychInfo and Google scholar were used to search for English -language articles from July 1, 2017, to August 18, 2017. Search terms included combined key words of Inflammatory bowel disease, Crohn’s disease, ulcerative colitis, randomized control trial, anxiety and depression. The search was restricted to RCTs published between 2007 and 2017 to identify the most recent psychological interventions for anxiety and depression for IBD patients presented through the research within the last 10 years. A manual search of references from retrieved articles was undertaken to identify additional articles related to the research topic.

Inclusion and Exclusion Criteria

The inclusion criteria were as follows: (1) English -language RCTs in peer reviewed journals, (2) compared a psychological intervention to a control group, and (3) measured anxiety or depression as a primary or secondary outcome at both pre- and post-intervention. Manual searches of references helped to identify one article related to the topic. Exclusion criteria include: studies limited to children and adolescents, reviews of the literature, expert opinion and RCTs in other languages.

Methodological quality

The Jadad Scoring of Quality of Reports of Randomized Clinical Trials (Jadad et al.,1996) was used to assess the methodological quality of each RCT. The Jadad score has been used for the quality appraisal of RCTs for more than 20 years and its psychometric properties has been evaluated. The maximum possible score is 5 (2 points for descriptions of randomization, 2 points for descriptions of double blinding, and 1 point for descriptions of withdrawals). A score of more than or equal to three points is considered of high quality studies and a score less than or equal to 2 is considered as low quality studies (Jadad et al.,1996). All the selected RCTs are of high quality as evidenced by the Jadad methodological quality score range of three to five. The details are included in Table 1. All studies had a control group and every study clearly identified inclusion or exclusion criteria. Every study included both men and women. Out of nine, only one study was double blinded (Jedel et al., 2014 ). Few studies (Mikocka-Walus et al., 2015; McCombie et al., 2016; Jedel et al., 2014; Vogelaar et al., 2014) presented power analysis to demonstrate they had an adequate sample size.

Analyses

The characteristics of each study were analyzed systematically with samples, design, purpose and by type of interventions. Further assessment included evaluation of sample characteristics, study interventions, length of time for interventions, and outcome measures related to anxiety and depression. The details are included in table 2. The study identified five different types of psychological interventions for anxiety and depression among IBD patients. It was difficult to merge the results by quantitative data synthesis due to the marked differences in the identified interventions and variations of methods across studies. Therefore the findings were synthesized narratively. Furthermore, emphasis was given to outcomes related to anxiety and depression in the discussion as the study was aimed to identify the psychological interventions for anxiety and depression among IBD patients. The other significant outcomes were narrated in the results.

Results

The search yielded 102 articles; Figure 1 contains the details of the selection process. After removing duplicate studies, 66 articles remained. After reviewing their abstracts for inclusion criteria, an additional 22 articles were excluded that ended up with 44 articles. From the 44 articles, an additional 24 articles were removed based on the inclusion and exclusion criteria. Finally 20 articles were reviewed and nine articles were selected based on the inclusion criteria. The details of final screening were included in Figure 1. The nine selected articles addressed cognitive behavioral therapy, mindfulness based therapy, breathing, movement and meditation, guided imagery with relaxation and solution focused therapy as the interventions to manage anxiety and depression among IBD patients as a primary or secondary outcome.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a type of psychotherapy where the participants were helped to analyze and convert unhelpful thinking styles and maladaptive behaviors (McCombie, Gearry, Andrews, Mulder, and Mikocka – Walus, 2016).

Diaz Sibaja, Comeche Moreno, and Mas Hess (2007) conducted a randomized control study on the effectiveness of CBT to reduce the emotional symptoms of inflammatory bowel disease. The samples were recruited from Spanish Crohn’s disease and Ulcerative Colitis Association with 33 patients in the treatment group and 24 patients in the control group. Anxiety and depression scores were measured between treatment and control group before and after cognitive behavioral therapy. The results highlighted significant improvement with anxiety (P< 0.001) and depression (P< 0.001) among treatment group compared to the control group. A follow up measurement of anxiety and depression scores at three, six and twelve months showed persistence of improvement on these emotional variables among IBD patients. In summary, this study pointed out that CBT as an effective intervention to induce and maintain lower levels of anxiety and depression among IBD patients (Diaz Sibaja et al., 2007).

Mikocka-Walus et al. (2015) studied the effect of CBT on IBD remission at 12 months as the primary outcome variable and QOL, anxiety and depression in IBD patients as the secondary outcome variable in Australia. The treatment group received standard care and CBT whereas the control group received the standard care only. The treatment group had the choice of receiving CBT face to face or online. A total of 174 participants was included in the study with 90 in the treatment group and 84 in the control group. The outcome measures were monitored at baseline and at six and twelve month intervals. The study results failed to identify a direct association between CBT and disease activity, QOL, anxiety and depression among IBD patients. However, there was a significant association (p = 0.034) founded between CBT and mental QOL (anxiety and depression) for those participants who were classified as ‘in need” (young, high baseline IBD activity, recently diagnosed and poor mental health) at 6 months compared to controls. Although no relationship found between two modes of CBT delivery (face to face vs computer based) and the outcome variables, the computer based group developed less coping (p = 0.045) with IBD in the subscale of precontemplation with mental health variables.

The researchers from the previous study (Mikocka-Walus et al.,2015) attempted to evaluate the data of the study after 24 months to see the influence of CBT on disease activity and mental QOL (anxiety and depression) for those participants who were classified as ‘in need” patients (Mikocka-Walus et al.,2017). Only 75 IBD patients remained in the study after 24 months (treatment with CBT = 30; control = 45) as opposed to 174 original participants. The evaluation of study results did not show any significant association between CBT and disease activity after 24 months. No significant association found between CBT and mental QOL (anxiety and depression) for those participants who were classified as ‘in need” at 24 months as compared to the initial study results (Mikocka-Walus et al.,2017). The authors attributed this difference to small sample size (n = 24) of “in need’ participants in the control group at 24 months follow up compared to 74 “in need’ participants at 6 months follow up.

McCombie, Gearry, Andrews, Mulder, and Mikocka – Walus (2016) conducted a study to test the effectiveness of computerized cognitive behavioral therapy (CCBT) among IBD patients in Newzeland. This was a multicenter trial with a total of 196 participants (113 in the treatment group and 86 in the control group). The primary measured outcome was the IBD specific health related QOL, and the secondary measures were generic health related QOL, anxiety and depression, perceived stress, social functioning, neuroticism, coping strategies and IBD related symptoms. Both the outcomes were measured at three and six month intervals. The treatment group received CCBT besides the usual IBD treatment, whereas the control group received treatment as usual. The study results showed that IBD specific health related QOL increased in the treatment group at 12 weeks (p = 0.01), but the improvement was not maintained at 6 months. On the contrary, none of the psychological secondary outcomes like anxiety, depression and stress were not significant at 12 weeks. However, patient’s perceptions about CCBT highlighted that 74% of participants enjoyed the program and recognized that it improved their physical or mental health (74%) and were ready to recommend it to others with gastrointestinal disorders (80%) demonstrating the high acceptability of the program among participants (McCombie et al., 2016).

Mindfulness Based Intervention

Mindfulness is a psychological skill that has been associated with mental health and well-being by focusing the attention for a moment to moment experiences without indwelling into unnecessary rationalization. The focus of mindfulness is to manage stress by different forms of meditation and group discussion to practice emotional skills in daily life (Neilson et al., 2015).

Schoultz, Atherton, and Watson (2015 conducted a study to test the effectiveness of mindfulness based cognitive therapy (MBCT) in IBD patients in Scotland. A total of 43 patients participated in the study, 21 in the treatment group and 22 in the control group. The treatment group received 8 weeks of MBCT and the control group received a leaflet titled ‘staying well with IBD’. The outcomes measured were depression, anxiety, dispositional mindfulness, disease activity and quality of life. The outcomes were evaluated at baseline, post intervention and after 6 months. The study results showed a significant improvement of scores and statistical significance in the MBCT group for depression (p = 0.027), trait anxiety (p = 0.048), dispositional mindfulness (p = < 0.034) at post intervention and at 6 months follow up. No association found between MBCT and other outcome measures.

Jedel et al., (2014) conducted a randomized double blinded time attention controlled study to find out the effects of mindfulness based stress reduction (MBSR) on disease course, quality of life, markers of inflammation, and psychological parameters in ulcerative colitis (UC) patients who were in remission. The study setting was in Chicago, USA with a total of 53 participants (27 in the treatment group and 26 in the control group). Patients were randomized to one of the two mind body courses (MBSR vs course given to time/attention control group). The MBSR intervention was given for 8 weeks to the treatment group. A course on mind/body medicine comprised of the effect of stress on physical and psychological health were scheduled weekly for the time attention control group. The outcomes were measured at baseline, 8 weeks, and at 6 and 12 months after the intervention. The study results report that MBSR did not significantly affect anxiety or depression in UC patients. There was no significant association found between MBSR and disease course, markers of inflammation and quality of life of UC patients. An additional outcome that was discovered after post – hoc analysis of the study was that mindfulness based therapy might be useful to prevent the flare ups in the subset of UC patients with increased stress.

Breathing, movement & Meditation

Gerbarg, et al. ( 2015) conducted a study to evaluate the effects of ‘Breath – Body- Mind -Workshop’ (BBMW) (breathing, movement and meditation) on anxiety, stress, depression, quality of life, and social function (psychological )and physical symptoms and inflammatory biomarkers (fecal calprotectin and serum C- reactive protein) in IBD patients. The study setting was in New York, USA with a total of 27 participants. The treatment group (n = 15) received the intervention of BBMW workshop whereas the control group received an educational seminar. The BBMW was offered for 9 hours on two different days. The control group was offered a 9 hour initial educational seminar followed by weekly educational seminar related to IBD topics for 6 weeks. The outcomes were measured for both treatment and control group before, during, and after their respective programs at weeks 0,6 and 26. The study results showed that BBMW participants had significant improvement in physical symptoms (p = 0.02), anxiety (p = 0.02), and quality of life (p = 0.01) between baseline and week 6. Furthermore, these improvements sustained at week 26 and extended to other psychological outcomes such as stress (p = 0.01), depression (p = 0.01), and social function (p = 0.001) at week 26.

Guided imagery with relaxation

Mizrahi, et al. ( 2012) studied the effect of guided imagery with relaxation training on anxiety and quality of life among patients with inflammatory bowel disease in Israel. The outcomes measured were anxiety, QOL, pain, depression, stress, mood and intestinal symptoms in patients with IBD. Thirty nine subjects completed the study; 18 in the treatment group and 21 participants in the control group. The treatment group received three individual relaxation training sessions at two week intervals for a 50 minute period. The control group completed symptom monitoring diaries at baseline and at the end of the trial. The outcomes were measured before and after the treatment. The study results highlighted statistically significant improvement in the treatment group in outcomes of reduced anxiety (p < 0.01), improvement in QOL and mood (p < 0.05), and reduced levels of pain and stress (p < 0.01), compared to the control group. No significant improvement in depression was noted between treatment and control group.

Solution Focused Therapy

Vogelaar, et al. (2014) conducted a study to evaluate the effectiveness of solution focused therapy (SFT) on fatigue and QOL as the primary outcome and anxiety and depression as the secondary outcome with many other variables. The outcomes were measured at baseline, and at the intervals of three, six and at nine months. The study setting was in the Netherlands with a total of 97 participants. The treatment group received SFT whereas the control group received care as usual. The study results reported a significant improvement with fatigue in the SFT group (p = <0.001) at 3 months, followed by a significantly lower depression scores in the SFT group (p = 0.03) at months compared to the control group. However, the change in depression levels did not sustain after 3 months and did not observe a significant difference between treatment and control group on anxiety scores.

Discussion

Comparison of CBT techniques among the four studies showed that the techniques vary in three studies (Diaz Sibaja et al., 2007; Mikocka-Walus et al., 2015; Mikocka-Walus et al., 2017; McCombie et al., 2016) and the same technique was used in two studies as the second study (Mikocka-Walus et al., 2017) was the follow up of the first study (Mikocka-Walus et al., 2015). However, relaxation and coping techniques were consistently included in CBT of all four studies. The mode of CBT delivery varies in each study such as face to face, and face to face or computer based (based on patient choice) in two studies, and computer based with the third study. Although, the face to face CBT delivery presented with best outcomes (Diaz Sibaja et al., 2007) related to anxiety and depression, it is difficult to draw a conclusion about the best mode of CBT delivery with only one study results.

The four studies that examined the cognitive behavioral therapy as a psychological intervention presented with mixed results about the effectiveness of CBT to control anxiety or depression among IBD patients (Diaz Sibaja et al., 2007; Mikocka-Walus et al., 2015; Mikocka-Walus et al.,2017; McCombie et al., 2016). Only two studies reported a statistical significance with improvement of anxiety and depression as a primary or secondary outcome (Diaz Sibaja et al., 2007; Mikocka-Walus et al., 2015). However, the improvement with anxiety and depression outcomes were not directly related to all treatment group participants in the study of Mikocka-Walus et al. (2015). The improvement in anxiety and depression outcomes after CBT were reported in a subset of IBD patients who had been reported as “in need” patients. However, the study failed to report the persistence of this improvement with “in need” patients after 24 months (Mikocka-Walus et al., 2017). All the studies performed a longitudinal assessment of outcomes to measure the sustainability of outcomes after the study period. Based on this assessment, persistence of improvement with anxiety and depression was only present in the study of Diaz Sibaja et al. (2007). However, Diaz Sibaja et al. (2007) used a control group only for initial assessment and comparison between treatment and control group was missing at three, six and twelve months. Based on the above discussed facts, the evidences are mixed to support CBT as an effective intervention to manage anxiety and depression among IBD patients.

Analysis of studies related to mindful based interventions demonstrated mixed evidence of mindful based interventions in managing anxiety and depression among IBD patients. Only one study (Schoultz et al., 2015) identified a strong and sustained relationship between mindful based therapy and anxiety and depression among IBD patients. However, both researchers ((Schoultz et al., 2015; Jedel et al., (2014) acknowledged a future research with large sample size and a multicenter trial to explore the distinct effect of mindfulness based therapy on anxiety and depression. Furthermore, Jedel et al. (2014), reported that self-reported good mental health of participants at baseline might have caused a ceiling effect on the results of the study and recommended to consider baseline mental status or mindfulness as a sampling criteria. The post -hoc analysis findings of Jedel et al., (2014) point out that mindfulness based therapy may not be effective with all the patients with IBD as the state of anxiety and depression vary among patients, but may be effective for IBD patients with psychological disturbance.

Analysis of study results of BBMW, guided imagery and SFT highlighted a sustained improvement with anxiety and depression among IBD patients in the study of BBMW compared to guided imagery and SFT; the SFT group reported lower depression scores at three months, but failed to report a sustained effect after three months (Gerbarg, et al., 2015; Mizrahi, et al., 2012; Vogelaar, et al., 2014) ) . However, the intervention with guided imagery reported improvement with anxiety and mood disorders after the intervention (Mizrahi, et al., 2012) whereas, no difference noted among the SFT group on anxiety scores (Vogelaar, et al., 2014). Unlike BBMW and SFT, the guided imagery did not report an improvement with depression among IBD patients after treatment. In summary, the interventions with BBMW, guided imagery and SFT presented with mixed evidences to support the effectiveness of these interventions to manage anxiety and depression among IBD patients. Among the three, BBMW stands out as the best one as it consistently improved both anxiety and depression among IBD patients.

Few studies documented about the type of reinforcement or follow up provided to reinforce or remind about the interventions to enhance compliance or to improve the effects of interventions consistent with the recommendations of McCombie et al. (2016) that “booster sessions” are needed to maintain the long term effects of CBT for depression. The researchers from both mindful based therapies, BBMW, guided imagery and relaxation incorporated a reinforcement session of these interventions through home practice during the study period. Telephone, text message or email reminders were provided by three CBT studies to enhance compliance during the study period (Mikocka-Walus et al., 2015 ; Mikocka-Walus et al., 2017; McCombie et al., 2016). On the contrary, the researchers of SFT (Vogelaar et al., 2014) used a single booster session at 6 months and included a partner, family member or a close relative in the 5th session. In conclusion, the majority of the researchers followed the opinion of Vogelaar et al. (2014) that an extended treatment period with a follow up is necessary to maintain the persistent effect of psychological interventions in IBD patients.

All the studies except one (Gerbarg, et al., 2015), included some form of initial psychological screening as an inclusion criteria before initiating the psychological interventions in their randomized controlled trial pointing out a homogenous group in terms of their mental health. All the RCTs demonstrated a high level of evidence (Level I – Level II) with results based on the evidence calculation of North American Spine Society (Levels of Evidence For Primary Research Question, 2005). The study settings vary across the studies from Spain, Australia, Newzeland, Scotland, USA, Israel, and Netherlands points out the feasibility and acceptability of different psychological interventions across diverse healthcare settings and cultures. Overall, the review presented a variety of psychological interventions to manage anxiety and depression and the positive effects of most of these interventions on the anxiety and depression outcomes of IBD patients.

Limitations and Recommendations for Future Research

A number of limitations observed among the selected studies for review. Many studies did not evaluate anxiety or depression as a primary outcome. Most of them evaluated anxiety or depression along with other variables such as QOL, physical symptoms, inflammatory biomarkers, physical symptoms, and stress to name a few. Future research is required to evaluate the distinct effect of psychological interventions on anxiety and depression of IBD patients.

Secondly, the disease activity of samples varies across the studies such as IBD patients in general, IBD in remission, ulcerative colitis with remission and active IBD patients. Moreover, no consistency observed for the delivered interventions among these different samples with IBD disease activity (CBT was evaluated among all IBD population and IBD with remission, mindfulness based therapy was evaluated among ulcerative colitis with remission vs all IBD patients, BBMW was evaluated among all IBD patients, guided imagery was evaluated among IBD patients with active disease and SFT was evaluated on IBD patients with remission). As a result, it was difficult to make conclusion about the suitability of a particular psychological intervention for a certain disease activity of IBD. More research is required with CBT, mindfulness based therapy, BBMW, guided imagery and SFT on different disease activities to have reliable results on the effectiveness of these interventions on different disease activities of IBD.

Only three studies (Mikocka-Walus et al., 2015; Mikocka-Walus et al., 2017; Jedel et al., 2014) measured the effect of psychological interventions on a subtype of IBD sample such as participants who are classified as in “need” and a subset of UC patients with increased stress. More research is required among these types of IBD population who are in “need’” or with increased stress to identify the well-defined effects of psychological interventions among them.

Failure to retain participants after six and twelve months were an observed problem among many studies (Schoultz et al.,2015; McCombie et al., 2016; Mikocka-Walus et al., 2015; Mikocka-Walus et al. , 2017). This might have affected the results with long term effects of psychological interventions in these studies; future research should focus on longitudinal assessment of anxiety and depression outcomes by improving the strategies that help with participant retention.

The other limitations were related to the mixed results of the psychological intervention, somewhat duplicate methodology of two studies and author bias related to work. It was difficult to provide an overall recommendation about the best psychological intervention for anxiety and depression due to the differences in interventions and outcome measures. The study of Mikocka-Walus et al. (2017) was the follow up of the first study (Mikocka-Walus et al. (2015) at 24 months. A single author screened all the abstracts, articles, data abstraction and quality screening. Few studies directly measured the outcomes of anxiety and depression and the descriptions of the outcomes were often vague; as a result, there may have been additional psychological interventions available to manage anxiety and depression among IBD patients that were not captured due to lack of clarity.

Implications for Practice

Analysis of the reviewed RCT’s lead to the conclusion that psychological interventions can be an option for management of anxiety and depression among IBD patients. Psychological interventions can be recommended as an adjuvant therapy besides pharmacological treatment to manage anxiety and depression among IBD patients. The nurses in the acute care settings or outpatient care settings should facilitate a discussion about the availability of these interventions with IBD patients to manage their anxiety and depression. Additionally, providers can screen patients based on the disease activity of IBD to refer them for appropriate psychological intervention of their choice as anxiety and depression has been associated with clinical disease recurrence in the IBD population (Mikocka-Walus, et al.,2016). Moreover, findings from the observational studies highlighted that psychological burden is more profound in patients with active IBD or patients in remission with ongoing gastrointestinal symptoms without inflammation, suggesting that psychological interventions would be more appropriate for these subcategories of patients (Gracie, et al., 2017)